1. A client taking haloperidol develops a high fever and
muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Tardive dyskinesia
D. Extrapyramidal symptoms (EPS)
Answer: B
Rationale: NMS is a rare but fatal reaction to antipsychotics.
Requires immediate intervention.
2. A client on lithium therapy has a sodium level of 128
mEq/L.
What is the nurse's best action?
A. Encourage low-sodium diet
B. Administer next dose
C. Hold the dose and notify the provider
D. Increase fluid restriction
Answer: C
Rationale: Hyponatremia can increase lithium toxicity risk.
Hold
the dose and notify the provider.
3. A client taking warfarin has an INR of 4.2. Which action
should
the nurse take?
A. Administer the next dose of warfarin
B. Hold the dose and notify the provider
C. Give vitamin K IV immediately
D. Prepare for platelet transfusion
Answer: B
Rationale: An INR >3.0 indicates increased bleeding risk.
The
nurse should hold the medication and notify the provider.
4. Which lab value should be monitored regularly for a
client on
statins?
A. BUN
B. AST and ALT
C. Sodium
D. Hematocrit
Answer: B
Rationale: Statins can cause liver damage. Monitor liver
enzymes
(AST/ALT).
5. A client taking isoniazid (INH) for tuberculosis develops
, numbness and tingling in their hands and feet. What should
the
nurse anticipate?
A. The need for increased calcium
B. Administration of pyridoxine (vitamin B6)
C. Discontinuation of therapy
D. Addition of prednisone
Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, often
prevented or treated with vitamin B6.
6. A client uses sublingual nitroglycerin. Which instruction
is
correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up
to 3
doses, and call 911 if no relief after the first.
7. A client taking carbidopa/levodopa reports facial
twitching
and eye spasms. What should the nurse do?
A. Reassure the client this is expected
B. Hold the dose and notify the provider
C. Administer diphenhydramine
D. Document and continue monitoring
Answer: B
Rationale: Facial twitching and spasms are signs of toxicity.
Notify
the provider to adjust dosage.
8. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
Rationale: Metoprolol can cause bradycardia. Always check
HR
before administering.
9. A client with hypothyroidism takes levothyroxine. Which
statement indicates effective therapy?
A. “I feel cold all the time.”
B. “My heart rate is slower than usual.”
muscle
rigidity. What should the nurse suspect?
A. Serotonin syndrome
B. Neuroleptic malignant syndrome (NMS)
C. Tardive dyskinesia
D. Extrapyramidal symptoms (EPS)
Answer: B
Rationale: NMS is a rare but fatal reaction to antipsychotics.
Requires immediate intervention.
2. A client on lithium therapy has a sodium level of 128
mEq/L.
What is the nurse's best action?
A. Encourage low-sodium diet
B. Administer next dose
C. Hold the dose and notify the provider
D. Increase fluid restriction
Answer: C
Rationale: Hyponatremia can increase lithium toxicity risk.
Hold
the dose and notify the provider.
3. A client taking warfarin has an INR of 4.2. Which action
should
the nurse take?
A. Administer the next dose of warfarin
B. Hold the dose and notify the provider
C. Give vitamin K IV immediately
D. Prepare for platelet transfusion
Answer: B
Rationale: An INR >3.0 indicates increased bleeding risk.
The
nurse should hold the medication and notify the provider.
4. Which lab value should be monitored regularly for a
client on
statins?
A. BUN
B. AST and ALT
C. Sodium
D. Hematocrit
Answer: B
Rationale: Statins can cause liver damage. Monitor liver
enzymes
(AST/ALT).
5. A client taking isoniazid (INH) for tuberculosis develops
, numbness and tingling in their hands and feet. What should
the
nurse anticipate?
A. The need for increased calcium
B. Administration of pyridoxine (vitamin B6)
C. Discontinuation of therapy
D. Addition of prednisone
Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, often
prevented or treated with vitamin B6.
6. A client uses sublingual nitroglycerin. Which instruction
is
correct?
A. Swallow the pill with water
B. Take up to 3 doses, 5 minutes apart
C. Store it in a warm area
D. Use it once weekly
Answer: B
Rationale: For chest pain, take 1 tablet every 5 minutes, up
to 3
doses, and call 911 if no relief after the first.
7. A client taking carbidopa/levodopa reports facial
twitching
and eye spasms. What should the nurse do?
A. Reassure the client this is expected
B. Hold the dose and notify the provider
C. Administer diphenhydramine
D. Document and continue monitoring
Answer: B
Rationale: Facial twitching and spasms are signs of toxicity.
Notify
the provider to adjust dosage.
8. A nurse is preparing to administer metoprolol. Which
assessment is priority?
A. Respiratory rate
B. Heart rate
C. Oxygen saturation
D. Blood glucose
Answer: B
Rationale: Metoprolol can cause bradycardia. Always check
HR
before administering.
9. A client with hypothyroidism takes levothyroxine. Which
statement indicates effective therapy?
A. “I feel cold all the time.”
B. “My heart rate is slower than usual.”
